PLEASE READ THE FOLLOWING NOTICESBEFORE COMPLETING THIS PROPOSAL FORM.

Your Duty of Disclosure–

Contracts of General Insurance

Before you enter into acontract of general insurance with anInsurer, you have a duty, under the Insurance Contracts Act 1984,to disclose to the Insurer every matter that you know, or couldreasonably be expected to know, is relevant to the Insurer’sdecision whether to acceptthe risk of the insurance and, if so, onwhat terms.

You have the same duty to disclose those matters to the Insurerbefore you renew, extend, vary or reinstate a contract of generalinsurance. Your duty however does not require disclosure of anymatter:

•

that diminishes the risk to be undertaken by the Insurer;

•

that is of common knowledge;

•

that your Insurer knows or, in the ordinary course of theirbusiness, ought to know;

•

as to which compliance with your duty is waived by the Insurer.

Non-Disclosure

If you fail to comply with your duty of disclosure, the Insurer maybe entitled to reduce their liability under the contract in respect of aclaim and/ or may cancel the contract.

If your non-disclosure is fraudulent, the Insurer may alsohave theoption of avoiding the contract from its beginning.

Change of Risk or Circumstances

The terms and conditions of any insurance policy offered by theInsurer will be based on the information provided to the Insurer.

If any material change occurs to the information provided on orwith this proposal form prior to the inception of the policy, it isessential that the Insurer is advised of the same prior to inceptionof any policy. Failure to do so on your part may prejudice anysubsequent claim underthe policy and/ or the continuation of theinsurance contract.

Claims Made Policy–

Professional Indemnity Policy

Any insurance contract (policy) that may be offered on the basis ofthis proposal form will provide insurance on a “claims made” basis.

This

means that the policy will indemnify you for claims madeagainst you and notified to the Insurer during the period ofinsurance. The policy will also respond to the written notification offacts that might give rise to a claim pursuant to Section 40(3) of

the Insurance Contracts Act 1984 which states;

“Where the insured gave notice in writing to the insurer of factsthat might give rise to a claim against the insured as soon as wasreasonably practicable after the insured became aware of thosefacts but before the insurance cover provided by the contractexpired, the insurer is not relieved of liability under the contract inrespect of the claim, when made, by reason only that it was madeafter the expiration of the period of the insurance cover provided bythe contract.”

The policy does not provide indemnity in relation to:

•

events that occurred prior to the retroactive date, if any,specified in the policy;

claimsmade against you prior to the commencement of theperiod of insurance;

•

claims made against you after the expiry of the period ofinsurance;

•

claims arising out claims or circumstances noted on thisproposal form or any previous proposal form;

•

claims

arising out of any facts or circumstances known to youat the commencement of the period of insurance where suchfacts or circumstances would have put a reasonable person inyour position on notice that a claim may be made against youin the future.

Theindemnity provided by the policy is subject to all the terms andconditions of the policy.

Surrender or Waiver of any Right of Contribution or Indemnity

Where another party would be liable to compensate you or hold youharmless for part or all of

any loss or damage otherwise covered bythe policy, but you have agreed with that party that you would notseek to recover any loss or damage from that party, you areNOTCOVERED

any liability assumed by the Insured under a contract, includingbut not limited to any express guarantee, warranty, contractualpenalty or

liquidated damages, unless such liability would haveattached to the Insured in the absence of such contract; or



any duty or obligation assumed by the Insured that is notassumed in the normal conduct of the Insured business

You should obtain appropriate

legal advice before agreeing to orsigning any such document.

Not a Renewable Contract

Any insurance policy offered by the Insurer will terminate at expiryof the specified period of insurance. There is no right to automaticextension or renewal of the policy. If you wish to effect similarinsurance for a subsequent period, it will be necessary for you tocomplete a new proposal form prior to the termination of theexpiring policy so that the Insurer may consider whether or not tooffer a replacement policy, and if so, on what terms.

Retroactive Liability

The contract does not provide cover

in relation to events that occurbefore the commencement of the contract unless retroactiveliability cover is requested in this proposal form AND THECONTRACT IS EXTENDED accordingly.

If you requirefurtherexplanation

please contact our office.

Average Provision

One of the insuring provisions of the Professional IndemnityContract of Insurance provides that where the amount required todispose of a claim exceeds the limit of the sum insured in thecontract the insurer shall be liable only for a part of

the total costsand expenses which shall be the same proportion of the totalexpenses as the contract limit bears to the total amount required todispose of the claim.

Privacy Policy

Perryman O’Grady Philpott Pty Ltd trading as Perrymans isconscious ofits obligations under the privacy legislation andregulations relating to the way we can collect, use, keep secure anddisclose personal information. We have developed a privacy policywhich explains what sort of personal information we hold about youandwhat we do with that information.

For further queries regarding any of the above please our PrivacyOfficer or refer to ourwww.perrymans.com/privacy-policy.

Important Instructions for Completing this Proposal Form



All questions must be answered in full. Failure to do so mayresult in delays in providing a quotation or effecting theinsurance.



Where a Yes/No response is indicated please tick or cross theapplicable box.



This form must be signed by at least one principal, partner ordirector of the principal entity seeking insurance after allnecessary enquiries have been made of theprincipals, partners,directors,employees andConsultants, Subcontractors & Agents

of all entities seeking insurance.



Where there is insufficient space to answer any question, oradditional documentation or information is required, pleaseprovide same by way of a clearly labelled attachment to thisproposal form and specify the applicable attachments in thespace provided

for each question.



Provision ofCV’s

and/orCompanyCapabilityStatement



If you require any assistance in completing this proposal formplease contact Perrymans.



If a contract of insurance is agreed, this proposal form will formthe basis of thecontract.

Other than for your Consultants, Subcontractors and Agentsinsured under this cover

do you ever enter intoagreements (ie. hold harmless) or otherwise waive any legal right or entitlement that you may have.

Yes

No

g)

Contractual Agreements–

Increased Contractual Liability

Do you ever enter into agreements that may serve to increase your liability above that which you would normally beliable in the absence of such a contract (ie.including but not limited to any express guarantee,warranty, contractualpenalty or liquidated

damages, or any duty or obligation assumed by the Insured that is not assumed in the normalconduct of the Insured business)

Yes

No

If you answer YES to any d), e) or f) g) above we will need

FULL DETAILof your involvement in the above. Your risk willneed to be referred to the Insurer for consideration:

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h)

Please give a brief description of the project, contract value, type of structure and fees derived from thetwo largest

Contracts / Projects

undertaken byyou

(as declared in Section 1 b) ie.Not

as an Employee)

during the last 5 years.

For newbusinesses, please describe projects you are likely to undertake.

Please provide a percentage (%) breakdown of the fee income by State or Territory

(Based on Previous Financialyear):

State

NSW

VIC

QLD

SA

WA

ACT

NT

TAS

O/Seas

Total

%

100%

SECTION 5: INSURANCE HISTORY

a)

Are you currently insured for Professional Indemnity?

Yes

No

If yes, please complete the table below for the last 5 years.

Name of Insurer

& Broker

Period Insured

SumInsured

Excess

$

$

$

$

$

$

$

$

$

$

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b)

After appropriate enquiry, has theproposer, or any party to be covered by this policy:

i.

ever had a professional indemnity or liability insurance policy refused, cancelled or avoided,

had a renewal declined(other than insurer exiting that area of insurance),or had special terms

or restrictions

imposed?

Yes

No

ii.

Ever been subject to disciplinary proceedings for professional misconduct?

Yes

No

iii.

Had

any claim(s) been made against you for professional negligence, error or omission, bodily injury

or property damage, in the past 5 years where the value of all claims notified exceed $20,000

including current reserves

Yes

No

iv.

Aware ofany circumstances not already notified to insurers which may give rise to a Claim

against you orany other party to be covered by this policy?

Yes

No

If

you answeredYES

to(i) & (ii)please provideFULLDETAILS

on your letterhead by separate attachment

If you answeredYES

to(iii) & (iv) please complete claim addendum at the end of this proposal

In all cases supporting detail should be provided.

SECTION6: LIMIT OF INDEMNITY REQUIRED

a)

Please selectthe amount of Indemnity required:

* Please indicatewhether you also require cover for Public Liability

Professional Indemnity

Public Liability

$1,000,000

$10,000,000

$2,000,000

$20,000,000

$5,000,000

Other–

ml敡獥e却at攺

A

Other–

ml敡獥e却at攺

A

b)

Retroactive Cover

This extends

cover under the policy

(to which this proposal relates)for liabilitiesarising from workas declared in thisproposal. No cover will be provided under the policy (to which this proposal relates) for known claims andcircumstances.

InsuranceFacilitycan providecover for consultants,subcontractors and agentsPROVIDED THAT they under thedirect control / supervision of the Insured provided the

professional activities

are the sameas

that declared by

the Insured

and they are declared in Section 1 b) of this proposal.Cover for consultants, subcontractors and agents issubject to no other cover being in place.

Please note

it is the responsibility of theProposerto ensure that allconsultants,subcontractors and agents are appropriatelyqualified / experienced for the role they are undertaking.

I/We confirm that all consultants, subcontractors and agents are engaged to undertake

professional activities same as the Insured:

N/A

Yes

No

I/We confirm that all consultants, subcontractors and agents are appropriately qualified

when engaged by the Insured:

N/A

Yes

No

After Inquiry, I the undersigned declare that:

1.

I have read and understood theIMPORTANT NOTICES RELATING TO THIS PROPOSAL

at the start of this proposalform.

2.

I confirm that I am authorised to act for and on behalf of all persons/parties who may be entitled to indemnity under anypolicy which may be issued pursuant to this proposal form and I acknowledge that I am completing the proposal on theirbehalf.

3.

The statements and particulars in this Proposal (which includes any attachments and information supplied) are true andcorrect and that I have not misstated or supressed any facts that may be material.

4.

I acknowledge that I have a continuing obligation to notify

you of any material changes. Should any material facts alterbetween the date of this Proposal (which includes any attachments and information supplied) and entering into anycontract of insurance to which this Proposal (which includes any attachments and

information supplied) relates, I willadvise you immediately.

5.

I understand and agree that this Proposal (which includes any attachments and information supplied) will form the basisof any Contract of Insurance arranged.

6.

I understand that the signing of this proposal form does not bind the proposer or insurer to complete this insurance.